Screening for domestic violence during pregnancy follow-up: evaluation of an intervention in an antenatal service.

To assess the impact of a brief training for obstetricians and midwives about screening for domestic violence during pregnancy follow-up and to identify barriers to a routine enquiry. A monocentric quasi-experimental study was performed in an obstetrics department in Paris, France. We asked patients during their pregnancy follow-up to complete a survey describing their demographic characteristics. They were also asked if a health professional had screened them for domestic violence during the current pregnancy. Exclusion criteria were refusal and inability to complete the survey alone. Health professionals attended a brief training about domestic violence. The intervention provided general information about domestic violence to alert health professionals (prevalence, risk factors, consequences on women's health, pregnancy, and children) and guidelines on screening and how to deal with women disclosing domestic violence. They also had to complete a survey about their knowledge and practice concerning domestic violence. Two months later, patients consulting for their pregnancy follow-up completed the same survey. Health professionals were not aware of the study's aim throughout its course. The primary outcome was the rate of patients screened for domestic violence during pregnancy follow-up. The secondary outcome was the identification of barriers to a routine enquiry. Four hundred ninety-five patients completed the first survey (control group): 21 patients (4.8%) had been screened for domestic violence. Twenty-one health professionals attended the intervention. Eight (38.1%) stated that they never screened for domestic violence, and 3 (14.3%) stated that they always did. Three hundred ninety-five patients completed the second survey (experimental group): 17 patients (4.3% vs 4.8%, p = 0.53) stated that they had been screened for domestic violence. The main barriers to screening mentioned by health professionals were the presence of the partner, the lack of awareness of the need to screen, uncomfortable feelings, and the difficulty to identify victims. There was no increased screening for domestic violence during pregnancy follow-up after a brief training of obstetricians and midwives. An early training during medical studies or more extensive training for professionals could be more efficient.

Mutations involving the SRY-related gene SOX8 are associated with a spectrum of human reproductive anomalies.

SOX8 is an HMG-box transcription factor closely related to SRY and SOX9. Deletion of the gene encoding Sox8 in mice causes reproductive dysfunction but the role of SOX8 in humans is unknown. Here, we show that SOX8 is expressed in the somatic cells of the early developing gonad in the human and influences human sex determination. We identified two individuals with 46, XY disorders/differences in sex development (DSD) and chromosomal rearrangements encompassing the SOX8 locus and a third individual with 46, XY DSD and a missense mutation in the HMG-box of SOX8. In vitro functional assays indicate that this mutation alters the biological activity of the protein. As an emerging body of evidence suggests that DSDs and infertility can have common etiologies, we also analysed SOX8 in a cohort of infertile men (n = 274) and two independent cohorts of women with primary ovarian insufficiency (POI; n = 153 and n = 104). SOX8 mutations were found at increased frequency in oligozoospermic men (3.5%; P < 0.05) and POI (5.06%; P = 4.5 × 10-5) as compared with fertile/normospermic control populations (0.74%). The mutant proteins identified altered SOX8 biological activity as compared with the wild-type protein. These data demonstrate that SOX8 plays an important role in human reproduction and SOX8 mutations contribute to a spectrum of phenotypes including 46, XY DSD, male infertility and 46, XX POI.

Surgery is not superior to dilation for the management of vaginal agenesis in Mayer-Rokitansky-Küster-Hauser syndrome: a multicenter comparative observational study in 131 patients.

BACKGROUND: Vaginal agenesis in Mayer-Rokitansky-Küster-Hauser syndrome can be managed either by various surgeries or dilation. The choice still depends on surgeon's preferences rather than on quality comparative studies and validated protocols. OBJECTIVE: We sought to compare dilation and surgical management of vaginal agenesis in Mayer-Rokitansky-Küster-Hauser syndrome, in terms of quality of life, anatomical results, and complications in a large multicenter population. STUDY DESIGN: Our multicenter study included 131 patients >18 years, at least 1 year after completing vaginal agenesis management. All had an independent gynecological evaluation including a standardized pelvic exam, and completed the World Health Organization Quality of Life instrument (general quality of life) as well as the Female Sexual Function Index and Female Sexual Distress Scale-Revised (sexual quality of life) scales. Groups were: surgery (N = 84), dilation therapy (N = 26), and intercourse (N = 20). One patient was secondarily excluded because of incomplete surgical data. For statistics, data were compared using analysis of variance, Student, Kruskal-Wallis, Wilcoxon, and Student exact test. RESULTS: Mean age was 26.5 ± 5.5 years at inclusion. In all groups, World Health Organization Quality of Life scores were not different between patients and the general population except for lower psychosocial health and social relationship scores (which were not different between groups). Global Female Sexual Function Index scores were significantly lower in the surgery and dilation therapy groups (median 26 range [2.8-34.8] and 24.7 [2.6-34.4], respectively) than the intercourse group (30.2 [7.8-34.8], P = .044), which had a higher score only in the satisfaction dimension (P = .004). However, the scores in the other dimensions of Female Sexual Function Index were not different between groups. The Female Sexual Distress Scale-Revised median scores were, respectively, 17 [0-52], 20 [0-47], and 10 [10-40] in the surgery, dilation therapy, and intercourse groups (P = .38), with sexual distress in 71% of patients. Median vaginal depth was shorter in dilatation therapy group (9.6 cm [5.5-12]) compared to surgery group (11 cm [6-15]) and intercourse group (11 cm [6-12.5]) (P = .039), but remained within normal ranges. One bias in the surgery group was the high number of sigmoid vaginoplasties (57/84, 68%), but no differences were observed between surgeries. Only 4 patients achieved vaginas <6.5 cm. Delay between management and first intercourse was 6 months (not significant). Seventy patients (53%) had dyspareunia (not significant), and 17 patients all from the surgery group had an abnormal pelvic exam. In the surgery group, 34 patients (40.5%) had complications, requiring 20 secondary surgeries in 17 patients, and 35 (42%) needed postoperative dilation. In the dilation therapy group, 13 (50%) needed maintenance dilation. CONCLUSION: Surgery is not superior to therapeutic or intercourse dilation, bears complications, and should therefore be only a second-line treatment. Psychological counseling is mandatory at diagnosis and during therapeutic management.

Robotic-assisted laparoscopic sacrocolpopexy for stage III pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Abdominal sacrocolpopexy is the gold standard treatment for pelvic organ prolapse and can be performed laparoscopically. Robotic assistance allows optimal dissection and placement of the prosthesis. We present a video of our technique along with the results on 90 patients. METHODS: We perform a posterior dissection down to the levator muscles and an anterior dissection down to the trigone. The meshes are made of polyester (mersuture®). The posterior mesh is sutured to the levator muscles, to the rectum above the anorectal junction, below the uterosacral ligaments, and to the isthmus/cervix. The anterior mesh is sutured to the vagina and the isthmus/cervix and attached to the promontory with a tension measured through a vaginal exam. RESULTS: We operated on 90 patients. There was an additional procedure in 71 cases (either subtotal hysterectomy, adnexectomy, adhesiolysis, or rectopexy). The mean operative time was 246 min (180-415). Perioperative complications were one vaginal effraction and a case of sigmoidal perforation during an adhesiolysis. Early complications were two cases of bowel hernia through port sites. The mean hospital stay was 3.48 days (2-11). The mean follow-up is 15.6 months (range 1-45). Six patients have a persistent stage II prolapse. We observed no retraction of the prosthesis and no dyspareunia. CONCLUSIONS: With this technique we performed a complete treatment for severe prolapse by a minimally invasive approach with a low rate of recurrence at this point.

Perioperative parameters to consider for enhanced recovery in surgery (ERS) in gynecology (excluding breast surgery).

The current review explores the Enhanced Rehabilitation in Surgery (ERS) approach in the specific context of gynecological surgery. Implementation of an ERS protocol in gynecological surgery reduces postoperative complications and length of stay without increasing morbidity. An ERS approach is based on maintaining an adequate diet and hydration before the operation, according to the recommended time frame, to reduce the phenomenon of insulin resistance, and to optimize patient comfort. On the other hand, the use of anxiolytic treatment as premedication is not recommended. Systematic preoperative digestive preparation, a source of patient discomfort, is not associated with an improvement in the postoperative functional outcome or with a reduction in the rate of complications. A minimally invasive surgical approach is preferrable in the context of ERS. Prevention of surgical site infection includes measures such as optimized antibiotic prophylaxis, skin disinfection with alcoholic chlorhexidine, reduction in the use of drainage of the surgical site, and prevention of hypothermia. Early removal of the bladder catheter is associated with a reduction in the risk of urinary tract infection and a reduction in the length of hospital stay. Prevention of postoperative ileus is based on early refeeding, and prevention of postoperative nausea-vomiting in a multimodal strategy to be initiated during the intraoperative period. Intraoperative hydration should be aimed at achieving euvolemia. Pain control is based on a multimodal strategy to spare morphine use and may include locoregional analgesia. Medicines should be administered orally during the postoperative period to hasten the resumption of the patient's autonomy. The prevention of thromboembolic risk is based on a strategy combining drug prophylaxis, when indicated, and mechanical restraint, as well as early mobilization. However, the eclectic nature of the implementation of these measures as reported in the literature renders their interpretation difficult. Furthermore, beyond the application of one of these measures in isolation, the best benefit on the postoperative outcome is achieved by a combination of measures which then constitutes a global strategy allowing the objectives of the ERS to be met.

'A caesarean section is like you've never delivered a baby': A mixed methods study of the experience of childbirth among French women.

The experience of childbirth has been technologized worldwide, leading to major social changes. In France, childbirth occurs almost exclusively in hospitals. Few studies have been published on the opinions of French women regarding obstetric technology and, in particular, caesarean section. In 2017-2018, we used a mixed methods approach to determine French women's preferences regarding the mode of delivery, and captured their experiences and satisfaction in relation to childbirth in two maternity settings. Of 284 pregnant women, 277 (97.5%) expressed a preference for vaginal birth, while seven (2.5%) women expressed a preference for caesarean section. Vaginal birth was also preferred among 26 women who underwent an in-depth interview. Vaginal birth was perceived as more natural, less risky and less painful, and to favour mother-child bonding. This vision was shared by caregivers. The women who expressed a preference for vaginal birth tended to remain sexually active late in their pregnancy, to find sexual intercourse pleasurable, and to believe that vaginal birth would not enlarge their vagina. A large majority (94.5%) of women who gave birth vaginally were satisfied with their childbirth experience, compared with 24.3% of those who underwent caesarean section. The caring attitude of the caregivers contributed to increasing this satisfaction. The notion of women's 'empowerment' emerged spontaneously in women's discourse in this research: women who gave birth vaginally felt satisfied and empowered. The vision shared by caregivers and women that vaginal birth is a natural process contributes to the stability of caesarean section rates in France.

Primary ectocervical epithelial cells display lower permissivity to Chlamydia trachomatis than HeLa cells and a globally higher pro-inflammatory profile.

The tumoral origin and extensive passaging of HeLa cells, a most commonly used cervical epithelial cell line, raise concerns on their suitability to study the cell responses to infection. The present study was designed to isolate primary epithelial cells from human ectocervix explants and characterize their susceptibility to C. trachomatis infection. We achieved a high purity of isolation, assessed by the expression of E-cadherin and cytokeratin 14. The infectious progeny in these primary epithelial cells was lower than in HeLa cells. We showed that the difference in culture medium, and the addition of serum in HeLa cultures, accounted for a large part of these differences. However, all things considered the primary ectocervical epithelial cells remained less permissive than HeLa cells to C. trachomatis serovar L2 or D development. Finally, the basal level of transcription of genes coding for pro-inflammatory cytokines was globally higher in primary epithelial cells than in HeLa cells. Transcription of several pro-inflammatory genes was further induced by infection with C. trachomatis serovar L2 or serovar D. In conclusion, primary epithelial cells have a strong capacity to mount an inflammatory response to Chlamydia infection. Our simplified purification protocol from human explants should facilitate future studies to understand the contribution of this response to limiting the spread of the pathogen to the upper female genital tract.

Axillary treatment in conservative management of operable breast cancer: dissection or radiotherapy? Results of a randomized study with 15 years of follow-up.

PURPOSE: Axillary dissection is the standard management of the axilla in invasive breast carcinoma. This surgery is responsible for functional sequelae and some options are considered, including axillary radiotherapy. In 1992, we published the initial results of a prospective randomized trial comparing lumpectomy plus axillary radiotherapy versus lumpectomy plus axillary dissection. We present an update of this study with a median follow-up of 180 months (range, 12 to 221 months). PATIENTS AND METHODS: Between 1982 and 1987, 658 patients with a breast carcinoma less than 3 cm in diameter and clinically uninvolved lymph nodes were randomly assigned to axillary dissection or axillary radiotherapy. All patients underwent wide excision of the tumor and breast irradiation. RESULTS: The two groups were similar for age, tumor-node-metastasis system stage, and presence of hormonal receptors; 21% of the patients in the axillary dissection group were node-positive. Our initial results showed an increased survival rate in the axillary dissection group at 5 years (P =.009). At 10 and 15 years, however, survival rates were identical in both groups (73.8% v 75.5% at 15 years). Recurrences in the axillary node were less frequent in the axillary dissection group at 15 years (1% v 3%; P =.04). There was no difference in recurrence rates in the breast or supraclavicular and distant metastases between the two groups. CONCLUSION: In early breast cancers with clinically uninvolved lymph nodes, our findings show that long-term survival does not differ after axillary radiotherapy and axillary dissection. The only difference is a better axillary control in the group with axillary dissection.

Donor site sequelae after autologous breast reconstruction with an extended latissimus dorsi flap.

The indications for autologous reconstruction are increasing. The standard procedure is the transverse rectus abdominis muscle flap; however, this flap has contraindications and drawbacks. The latissimus dorsi muscle flap is simple and reliable. Hokin et al. demonstrated in 1983 that this flap can be extended and used for breast reconstruction without an implant. Since then, it has been widely studied in this setting and is known to provide good aesthetic results. Dorsal sequelae, conversely, were not appraised. The aim of this study was to assess objective and subjective dorsal sequelae after the harvest of an extended flap. Forty-three consecutive patients who had had breast reconstruction with an autologous latissimus dorsi flap were assessed by a surgeon and a physiotherapist for muscular strength and shoulder mobility. Patient opinion was studied through a questionnaire. Mean delay between the operation and the evaluation was 19 months. Early complications, mainly dorsal seromas, were frequent after the harvest of an extended flap (72 percent). There was no late morbidity and, especially, no flap loss or partial necrosis. As for functional results, 37 percent of the patients had complete adjustment and 70 to 87 percent demonstrated no change in shoulder strength. Sixty percent of the patients experienced no limitation in everyday life, and 90 percent said they would undergo this procedure again. The authors show that dorsal sequelae after an extended latissimus dorsi flap are minimal and that this technique compares favorably with the transverse rectus abdominis muscle flap.

Sentinel node localization should be interpreted with caution in midline vulvar cancer.

OBJECTIVE: Carcinomas of the vulva situated on the midline or close to it, are supposed to have a bilateral lymphatic drainage. The aim of this study was to evaluate sentinel node identification in these tumors. METHODS: Between April 2002 and February 2004, 17 patients with operable vulvar cancer situated on, or close to the midline were entered in a prospective study. All patients underwent sentinel node identification with (99m)Tc-labelled nanocolloid (preoperative lymphoscintigraphy and intraoperative use of a handheld probe). Depending on the surgeon, intraoperative blue dye was associated. Radical excision of the tumor and routine bilateral lymphadenectomy were then performed. Sentinel nodes were sent separately for histologic examination. Negative sentinel nodes on hematoxylin/eosine were further examined with immunohistochemistry. RESULTS: One or more sentinel nodes were identified in the 17 patients and in 21 of the 34 groins. In 5 patients, the sentinel nodes were metastatic. There was no false negative (negative sentinel node and metastatic non-sentinel node). In 13 patients, lymphoscintigraphy and then intraoperative identification suggested a unilateral drainage of the tumor with sentinel nodes localized in only one groin. Among these 13 patients, 3 groins with no sentinel node identified contained in fact massively metastatic nodes. CONCLUSION: Unilateral finding of a sentinel node in tumors of the midline does not preclude a metastatic node in the other groin. Lymph node assessment should remain bilateral in these lesions.

Treatment of vaginal outflow tract obstruction in graft-versus-host reaction.

We describe five patients with vaginal stenosis that was due to chronic graft-versus-host reaction after bone marrow transplantation. All patients underwent surgical procedures followed by local corticosteroids administration. Vaginal function was restored in all cases. This satisfactory result persists in the long term.

Macroscopic quality control improves the reliability of blue dye-only sentinel lymph node biopsy in breast cancer.

BACKGROUND: One of the problems of sentinel lymph node (SLN) biopsy is the risk of false negatives. At the Institut Curie, to reduce the false-negative rate, we have developed a histological quality control of the SLN performed by blue dye alone, which consists of verification of the SLN blue stain by the pathologist. METHODS: A total of 324 patients underwent an SLN biopsy procedure with patent blue dye only followed by an immediate axillary dissection. Initially, SLNs were checked to ensure that they were blue by macroscopic examination. Finally, a search for immunohistochemistry micrometastasis was performed. RESULTS: In 277 (85.5%) of 324 patients, an SLN was identified by the surgeon. After standard examination, the false-negative rate was 11.1% (10 of 90). After macroscopic checking of the 197 negative SLNs, 167 of the 197 were confirmed blue, and there were 5 false negatives, which brought the false-negative rate down to 5.6% (5 of 90). Sixty SLNs out of the 167 confirmed blue SLNs were then proved to be immunohistochemically micrometastatic, and there were 3 false negatives, giving a final false-negative rate of 2.2% (2 of 90; P =.002). CONCLUSIONS: In this series, the procedure of pathologic analysis of the SLN has resulted in a significant reduction of the false-negative rate.